With a 21-day lockdown kicking in across the country, the public health idea that drives this measure is quite simple: a lockdown prevents the virus from spreading from those who have already contracted it to those who have not. Simultaneously, those who have already contracted it will begin to develop symptoms, get tested and get treated. Much of the focus has been on the first part - how will a lockdown be implemented and how do people survive it. But the second part is just as important from a public health perspective, and just as likely to have significant structural flaws.
Accessing healthcare in India is deeply divided territory. Multiple nationwide surveys find that the rich are more likely to access healthcare than the poor. The National Sample Survey on the Social Consumption of Health found that in 2017-18, the richest one-fifth of rural Indians made up nearly one-third of all hospitalisations in the previous year, while the poorest one-fifth made up just over a tenth of hospitalisations.
Nor is this necessarily because the rich experience illness more often. The poorest are most likely to report ill-health and the richest the least likely, the nationally representative India Human Development Survey (IHDS) found in 2011-12. Of special significance in the context of the novel coronavirus is the IHDS’s finding that the poorest are most likely to have experienced a cough, fever and diarrhoea - all of which are also symptoms of the novel coronavirus - as are disadvantaged groups such as Dalits and Muslims.
The prevalence of respiratory illness is on the whole high - 18.7% of respondents reported having experienced these symptoms in the preceding month, raising worrying questions about the ability of the system to identify COVID-19 cases in this context. India’s poorest states are the ones with the highest prevalence rates.
Even in terms of longer illness, while the poorest are most likely to suffer from such chronic illness, the richest come next. However chronic conditions do not incapacitate the rich in quite the same way as they do the poor.
The general belief in India is that richer people’s lifestyles - more sedentary time, richer and fattier foods - make them more likely to suffer from non-communicable diseases that have been identified as comorbidities (underlying health conditions that raise the risk of mortality from the virus) including high blood pressure, diabetes and heart disease.
Research based on the IHDS finds that richer people have a higher likelihood of having these non-communicable diseases. But living in a richer household is a considerable safeguard against death from disease - richer people are less likely to die from NCDs than poor people with NCDs. The overall mortality rates of the rich are also lower than that of the poor.
Costs are a clear factor when it comes to decisions around seeking medical treatment. For coughs and fevers, the median expenditure remained virtually the same for the bottom 80% of the country despite a wide difference in their incomes. The poor and the middle class access treatment for such common illnesses the same way - the majority in private clinics - and are charged the same amount. Only the top 20% of the country, those living in metros and upper caste Hindus, could pay more for treating such illnesses.
Medical treatment can drive poor families into debt. In 2013, the most recent year that such a survey was conducted, the NSS found that medical treatments formed a greater component of total household debt in poorer households than in richer households.
As of the 2017-18, 85% of rural Indians, and 81% of urban Indians were not covered by any insurance scheme and the poorest were the least likely to have hospital expenses reimbursed, NSS data shows. Since then, the Ayushman Bharat scheme has increased coverage, and the government has now said that COVID-19 cases will be covered by the scheme. However, the scheme is rigorously means-tested - a person earning over ₹10,000 per month or owning a refrigerator or a motorbike is ineligible.
The 21-day Indian lockdown is putting a huge cost on its working poor and middle class. The costs are being borne with the expectation that COVID-19 cases will be quickly identified and treated. But for this to happen, India will have to substantially alter its healthcare-seeking behaviour of the poor. For decades, India’s poor, although in worse health, have been least likely to get medical help.
For this fast-spreading virus to be stopped, India will have to demonstrate to the poor that free or cheap treatment will be made accessible to them. Until then, a lockdown will only delay the inevitable.
Rukmini S. is a Chennai-based journalist